In a haste, I slammed the door, without realizing one of my fingers was lodged between the seams. Immediately, a sharp pain seared through my finger, tracing up to my forearm. When the nail bed on my finger turned purplish black, my mother decided to take me to the Emergency Room (ER). After spending a few hours in the lobby, I was called into a room in the back where the emergency doctor on call examined my finger unceremoniously, concluding that a puncture was needed to alleviate the pressure building beneath my finger. He gripped my hand and with a needle pressed down on my nail. I could not control my tears as they slipped down my cheeks, barely stifling my cry as the pain jolted through my forearm once again. I looked around the room to the two interns who were all too absorbed with the procedure to sympathize with me.
My experience in the ER that day, while trivial in nature, serves to illustrate a problem that has been reported to pervade every aspect of healthcare: the apparent disconnect between the patient and the provider delivering care. In his recent book, Being Mortal, Brigham & Women’s neurosurgeon Atul Gawande discusses the issue of lack of communication between doctors and patients and how that results in omission of important details. When providing high-cost care to patients, this often times results in negative disease prognosis and long term health care outcomes. In chronic patients who require extensive, invasive treatment, the question of the patient’s suffering is often ignored when deciding treatment plans.
For decades following its inception, the unspoken mantra of western allopathic medicine has been to treat aggressively with the ultimate goal of prolonging life.
For decades following its inception, the unspoken mantra of western allopathic medicine has been to treat aggressively with the ultimate goal of prolonging life. However, a question that many physicians have been grappling with, especially with the advent of patient centered care, is at what point in a patient’s treatment timeline should aggressive care stop and end of life care begin? On any given day, at least five of the eight hospital beds in the ICU are taken up by chronically ill patients with very poor prognosis. In their final days, these patients are subjected to a multitude of invasive procedures and are constantly monitored through the jumble of tubes and cables attached to machines that whir and whine, inundating the room with a cacophony of beeps and alarms. With the increasing dominance of medical technology in recent times, the care for these patients has been primarily modeled around anatomical pathology, a system in which disease is diagnosed and treated based on microscopic and macroscopic examination of the patient’s organs and tissue. As a consequence, the holistic care of the patient often times takes a backseat in creating a care plan.
According to the CDC survey study The Concentration of Healthcare Spending, in the year 2009 almost 20% of total Medicare spending was spent on 1% of the population which equates to approximately $90,000 per patient. The elderly in the United States, defined as adults older than 64 years, compose 13% of the total population but account for 40% of Medicare spending. The extensive use of medical technology to prolong the final years of life in an ICU, where a day’s stay costs an average of $1500, drives up the cost of total patient care. But what effect does this have on bettering the quality of life for the patient?
The Dartmouth Atlas of Health Care report, a study detailing the last six months of patients receiving intensive treatment, reveals that 80% of ICU patients wish to die at home and not in a hospital bed. The healthcare providers’ and families’ aversion to forgo treatment is often at odds with the patient’s preferences. In an abstract published in the Annals of Internal Medicine, the authors make the observation that “dramatic shifts in attitudes and interventions” are needed for end-of-life care of patients in the ICU, with the focal point being intensive palliative care as opposed to “traditional intensive rescue care”.
The healthcare providers’ and families’ aversion to forgo treatment is often at odds with the patient’s preferences.
The question of holistic and end of life care brings about the bigger question of the traditional approach of western allopathy. Is it time for us to radically rethink how we approach medicine? Western medicine has historically taken a mechanistic approach to providing care for the patient, shunning any method that had not undergone extensive scientific scrutiny. As a result, the art of healing as practiced by many civilizations from the Greeks in the West to the Chinese and Indians in the East, and its humanistic roots that were established centuries ago, has been largely ignored. Until recently, when Youyou Tu was co-awarded the 2015 Nobel Prize in Physiology or Medicine for developing the antimalarial drug artemisinin, the medical community had been recurrently dismissive of alternative and complementary care. Yu’s nomination is a testament to the benefits of alternative approaches to medicine, as her work was the first to find an effective treatment for malaria by testing 2000 remedies from traditional Chinese medicine before isolating artemisinin from the extract of the wormwood plant Artemisia annua. The significance of Yu’s work cannot be understated since her approach to the problem at hand decidedly deviated from standard practice in pharmaceutical research which usually involves performing high throughput screening of largely random biomolecules.
It is necessary that we rethink western allopathic medicine so that we may ultimately not treat a depersonalized disease but instead care for the holistic person.
One of the prime tenets of the American Medical Association is delivering patient-centered care. According to its mission and guiding principles, the “AMA embraces the need for change and believes physician leadership is critical to the successful evolution of health care in a patient focused delivery system”. However, the degree to which modern medicine implements this principle should be scrutinized. The question of end of life and hospice care and the incorporation of alternative and complementary medicine elucidate the vast number of issues challenging the traditional approach to care that need to be explored seriously. It is necessary that we rethink western allopathic medicine so that we may ultimately not treat a depersonalized disease but instead care for the holistic person.
AMA Mission and Guiding Principles. (2015). American Medical Association. Retrieved from http://www.ama-assn.org/ama/pub/about-ama.page?
Callaway, E., & Cyranoski, D. (2015). Anti-parasite drugs sweep Nobel prize in medicine 2015. Nature, 526(7572), 174-175. http://dx.doi.org/10.1038/nature.2015.18507
Dasta, J. F., McLaughlin, T. P., Mody, S. H., & Piech, C. T. (2005). Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Critical care medicine, 6, 1266–1271.
End of Life Care. (2012). The Dartmouth Atlas of Health Care. Retrieved from http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=18
Faber-Langendoen, K., & Lanken, P. N. (2000). Dying patients in the intensive care unit: forgoing treatment, maintaining care. Annals of internal medicine, 11,886–893.
Schoenmann, Julie (2012). The Concentration of Healthcare Spending. National Institute for Healthcare Management. Retrieved from http://www.nihcm.org/pdf/DataBrief3%20Final.pdf